Doula, master's of public health graduate, new IBCLC, and feminist. I'm reflecting on my studies, reflecting on other people's studies, posting news, telling stories, and inviting discussion on reproductive health from birth control to birth to bra fitting.

Friday, June 27, 2008

Balancing the rights of women, and best outcomes for babies

OK, after a lot of writing and thinking I've started to answer Seth's three questions (see my last post for what those questions were, and what they were about). I'm going to address the first and last questions today, and the middle question tomorrow.

First, let's talk about the basic reason that the abortion rights debate is able to exist: because there are two entities at stake, and they are biologically inseparable. We do not have arguments about whether once you buy a dog, you have to keep that dog for a minimum of nine months, because you don't. If it doesn't work out, you can find a new home for it, end of story.

When women become pregnant, they have two choices: terminate the pregnancy, or be pregnant for nine months and give birth. You cannot pop a fetus out as soon as you realize it's there and give it someone else to handle. If it's going to continue, the mother is going to have to offer it a space in her body and, in whatever way she chooses, her life.

There are a lot of opinions on when "life" for the fetus begins (conception? forty days? month seven?) and a lot of opinions on how this bears on the mother's rights to control what's going on inside her body and in her life. But bear with me when I say that in the end, people seem to fall along a spectrum of positions. One extreme is "the mother has the right to do whatever she wants with anything to do with her body", and the other extreme is "the mother's body is now the host to the fetus and is always less important than the fetus' survival". There are laws being argued all along this spectrum. Does a woman have a right to a late-term abortion if her health is threatened? Should she be charged with child endangerment if she takes drugs in the ninth month?

This pairs the first and last questions very nicely:

1. If the obstetrician truly believed there was a serious risk to not performing a C-section, did he do the wrong thing? Did the hospital director? Did the judge? Did the sheriff?

3. To what degree, if any, should the best outcome for the unborn child be taken into account if it is contrary to the wishes of the mother? (Whether the two actually are in conflict is not the issue for this question.)

On one end of this spectrum, the obstetrician has acted correctly. The obstetrician sees a situation in which he feels the mother is endangering her child. He goes to the hospital director and the judge, and explains why he believes this - because she is laboring after having had a previous cesarean, she has a higher risk for uterine rupture. If her uterus ruptures, the baby could die. While some states permit parents to decline care for their children - even lifesaving care - based on personal religious beliefs, this mother isn't basing her decision on Christian Science or other religious beliefs rejecting medical care. In the doctor's view, she should be legally forced to give her baby the best medical care possible.

This is where we come back to the fact that the baby is not a discrete entity. To provide Mrs. P's baby with the perceived best care, they will need to force this woman to lie down on a table, submit to anesthesia, and have her uterus cut open. She will then need to have it sewn up and undergo the long, painful healing process from major abdominal surgery. While a repeat cesarean poses risks to the mother (although a uterine rupture would also risk her life, this does not seem to be a factor in the legal decision), the perceived risk to the baby is considered more important.

This woman, who had been offered and refused to consent to a procedure, saw the law used to physically enforce one doctor's opinion - that for the benefit of her child, her body and her wishes about her body were completely irrelevant. If we believe that this is true - that when it comes to the health of the baby, women's bodies are second priority - then we could agree the doctor acted correctly. Suffice it to say that I don't fall on that end of the spectrum. In the last question, we're asking to what degree the baby's health should be taken into account. I believe that a woman who understands the risks and benefits of her choices is taking the best outcome for her child into account already. Doctors may disagree, but ultimately it's the mother's decision. Why? Because it's her body. No one should be forced to undergo medical procedures without their consent. If we accept this, it's a slippery slope to so many other infringements on women's rights.

I think looking at the medical evidence makes this even clearer. When Mrs. P refused a cesarean on behalf of herself and her child, she was indeed placing her child at a slightly higher risk - but only slightly. Some parents refuse to vaccinate their children, which carries a small, but real risk of serious illness and death. Parents who don't vaccinate may have to put up with a lot of forms to fill out when it comes to school enrollment, but they are not arrested and forced to vaccinate their children.

Childbirth Connection reviews the evidence and states that:

"Best research suggests that about 1.4 extra babies die due to problems with the scar in every 10,000 VBAC labors, compared with planned c-section deliveries. Thus, over 7,000 women would need to experience risks of surgical birth to prevent the death of 1 baby from scar problems during VBAC.Added likelihood for a woman with a known low-transverse (horizontal) scar: LOW for death of the baby around the time of birth compared with repeat c-section."

(Click here for the original statement and more research on VBAC versus repeat C-section from Childbirth Connection.)

Many, many hospitals and doctors permit women to attempt VBACs; this doctor was certainly not acting in lockstep with every other medical professional. Rather, he was acting on a personal bias about the risk of VBACs. Why did he feel justified in sending a sheriff to this woman's house, arresting her, and strapping her to an operating table? Maybe because so many people consider women - especially in the area of reproduction - nothing but vessels. In that worldview, it's all right to force a woman to have a c-section, or forbid her from having an abortion, or live with the consequences of botched abortions and dead women. It's all the same. And that's why this story makes me physically ill.